Thomas M. Todoran

Prevalence of Optimal Treatment Regimens in Patients With Apparent Treatment-Resistant Hypertension Based on Office Blood Pressure in a Community-Based Practice Network

Hypertensive patients with clinical blood pressure (BP) uncontrolled on ≥3 antihypertensive medications (ie, apparent treatment-resistant hypertension [aTRH]) comprise ≈28% to 30% of all uncontrolled patients in the United States. However, the proportion receiving these medications in optimal doses is unknown; aTRH is used because treatment adherence and measurement artifacts were not available in electronic record data from our >200 community-based clinics Outpatient Quality Improvement Network. This study sought to define the proportion of uncontrolled hypertensives with aTRH on optimal regimens and clinical factors associated with optimal therapy. During 2007–2010, 468 877 hypertensive patients met inclusion criteria. BP <140/<90 mm Hg defined control. Multivariable logistic regression was used to assess variables independently associated with optimal therapy (prescription of diuretic and ≥2 other BP medications at ≥50% of maximum recommended hypertension doses). Among 468 877 hypertensives, 147 635 (31.5%) were uncontrolled; among uncontrolled hypertensives, 44 684 were prescribed ≥3 BP medications (30.3%), of whom 22 189 (15.0%) were prescribed optimal therapy. Clinical factors independently associated with optimal BP therapy included black race (odds ratio, 1.40 [95% confidence interval, 1.32–1.49]), chronic kidney disease (1.31 [1.25–1.38]), diabetes mellitus (1.30 [1.24–1.37]), and coronary heart disease risk equivalent status (1.29 [1.14–1.46]). Clinicians more often prescribe optimal therapy for aTRH when cardiovascular risk is greater and treatment goals lower. Approximately 1 in 7 of all uncontrolled hypertensives and 1 in 2 with uncontrolled aTRH are prescribed ≥3 BP medications in optimal regimens. Prescribing more optimal pharmacotherapy for uncontrolled hypertensives including aTRH, confirmed with out-of-office BP, could improve hypertension control.

Catheter-Based Therapies for Massive Pulmonary Embolism

Massive pulmonary embolism carries a high mortality rate as a result of right ventricular failure. In addition to anticoagulation, systemic thrombolysis is the standard first line of therapy for patients with life-threatening massive pulmonary embolism. Surgical embolectomy is often considered in patients with contraindications to receiving systemic thrombolysis or when thrombolysis has failed. Surgical embolectomy is not without inherent risk and limitations.Although there is a paucity of large clinical trials, available data suggests catheter-based treatment of massive pulmonary embolism restores hemodynamic stability and thus is an alternative to surgical therapy.

Percutaneous revascularization of long femoral artery lesions for claudication: patency over 2.5 years and impact of systematic surveillance.

Background: Angioplasty and stenting are preferred treatments for revascularizing femoral artery lesions up to 100 mm, but surgical bypass is recommended for longer lesions. We assessed long‐term patency after percutaneous revascularization of long femoral artery lesions for claudication with intensive out‐patient surveillance. Methods: We followed a cohort of 111 consecutive patients receiving angioplasty or stenting in 142 limbs in two institutions. Patients were followed for 2.5 years, and event curves and multivariable survival analysis used to compare outcomes in three groups according to lesion length (< 100 mm, 100–200 mm, and greater than 200 mm). Failed patency was defined as recurrence of symptoms with a decline in ankle brachial index, or stenosis identified by duplex ultrasound, or reintervention. Results: Compared to lesions less than 100 mm, longer lesions had higher failed primary patency (100–200 mm: HR = 2.0, P = 0.16, >200 mm: HR = 2.6, P = 0.03). Failed secondary patency was similar for short and intermediate lesions (< 5% incidence), but trended higher for lesions >200 mm (HR = 4.2, P = 0.06). An initial procedure residual stenosis greater than 20% was the only significant multivariable factor related to poorer long‐term patency (HR = 15.8, P = 0.003). Compared to short lesions, the gain in long‐term patency with out‐patient surveillance and reintervention was higher for longer lesions and significantly so for intermediate lesions (100–200 mm = 23% versus <100 mm = 8%, P = 0.041). Conclusion: Percutaneous treatment of long femoral artery lesions can provide acceptable long‐term patency for patients with claudication when out‐patient surveillance is used to identify patients who require repeat interventions. Future long‐term studies should consider overall patency encompassing more than one percutaneous reintervention.

Left ventricular end-diastolic pressure affects measurement of fractional flow reserve

BACKGROUND Fractional flow reserve (FFR), the hyperemic ratio of distal (Pd) to proximal (Pa) coronary pressure, is used to identify the need for coronary revascularization. Changes in left ventricular end-diastolic pressure (LVEDP) might affect measurements of FFR. METHODS AND MATERIALS LVEDP was recorded simultaneously with Pd and Pa during conventional FFR measurement as well as during additional infusion of nitroprusside. The relationship between LVEDP, Pa, and FFR was assessed using linear mixed models. RESULTS Prospectively collected data for 528 cardiac cycles from 20 coronary arteries in 17 patients were analyzed. Baseline median Pa, Pd, FFR, and LVEDP were 73 mmHg, 49 mmHg, 0.69, and 18 mmHg, respectively. FFR<0.80 was present in 14 arteries (70%). With nitroprusside median Pa, Pd, FFR, and LVEDP were 61 mmHg, 42 mmHg, 0.68, and 12 mmHg, respectively. In a multivariable model for the entire population LVEDP was positively associated with FFR such that FFR increased by 0.008 for every 1-mmHg increase in LVEDP (beta=0.008; P<0.001), an association that was greater in obstructed arteries with FFR<0.80 (beta=0.01; P<0.001). Pa did not directly affect FFR in the multivariable model, but an interaction between LVEDP and Pa determined that LVEDPs effect on FFR is greater at lower Pa. CONCLUSIONS LVEDP was positively associated with FFR. The association was greater in obstructive disease (FFR<0.80) and at lower Pa. These findings have implications for the use of FFR to guide revascularization in patients with heart failure. SUMMARY FOR ANNOTATED TABLE OF CONTENTS The impact of left ventricular diastolic pressure on measurement of fractional flow reserve (FFR) is not well described. We present a hemodynamic study of the issue, concluding that increasing left ventricular diastolic pressure can increase measurements of FFR, particularly in patients with FFR<0.80 and lower blood pressure.

Alcohol septal ablation for obstructive hypertrophic cardiomyopathy: Outcomes in young, middle-aged, and elderly patients

We compared the efficacy and safety of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) in young, middle‐aged, and elderly patients.

Comparison of percutaneous coronary intervention safety before and during the establishment of a transradial program at a teaching hospital.

This study sought to examine the safety of percutaneous coronary intervention (PCI) before and during de novo establishment of a transradial (TR) program at a teaching hospital. TR access remains underused in the United States, where cardiology fellowship programs continue to produce cardiologists with little TR experience. Establishment of TR programs at teaching hospitals may affect PCI safety. Starting in July 2009 a TR program was established at a teaching hospital. PCI-related data for academic years 2008 to 2009 (Y1) and 2009 to 2010 (Y2) were prospectively collected and retrospectively analyzed. Of 1,366 PCIs performed over 2 years, 0.1% in Y1 and 28.7% in Y2 were performed by TR access. No major complications were identified in 194 consecutive patients undergoing TR PCI, and combined bleeding and vascular complication rates were lower in Y2 versus Y1 (0.7% vs 2.0%, p = 0.05). Patients treated in Y2 versus Y1 and by TR versus transfemoral approach required slightly more fluoroscopy but similar contrast volumes and had similar procedural durations, lengths of stay, and predischarge mortality rates. PCI success rates were 97% in Y1, 97% in Y2, and 98% in TR cases. TR PCIs were performed by 13 cardiology fellows and 9 attending physicians, none of whom routinely performed TR PCI previously. In conclusion, de novo establishment of a TR program improved PCI safety at a teaching hospital. TR programs are likely to improve PCI safety at other teaching hospitals and should be established in all cardiology fellowship training programs.

TREATMENT RESISTANT HYPERTENSION IN A COMMUNITY-BASED PRACTICE NETWORK

Treatment resistant hypertension (TRH) is defined by blood pressure (BP) uncontrolled on ≥3 or controlled on ≥4 BP medications including a diuretic at optimal doses. The prevalence of TRH is uncertain. Electronic record data were analyzed from >200 OQUIN practices in the Southeast US. From 2007

Renal Sympathetic Denervation for Blood Pressure Control: A Review of the Current Evidence and Ongoing Studies

Hypertensive heart disease is the leading cause of mortality and morbidity in the United States. Despite widespread availability of medical therapy, it remains a challenge to treat. Autonomic nervous system imbalance resulting in overactivity of the sympathetic nervous system is integral to the development of hypertension and ultimately the development of hypertensive heart disease. Although the results with renal sympathetic denervation so far have been encouraging, optimism has recently been tempered with the broadcast alert from Medtronic, the sponsor of Symplicity HTN‐3, that the trial did not meet its primary efficacy endpoint. The principal focus of this article is to review the developments in renal sympathetic denervation for the treatment of resistant hypertension.

Comparison of Lipid Deposition at Coronary Bifurcations Versus at Nonbifurcation Portions of Coronary Arteries as Determined by Near-Infrared Spectroscopy

Atherosclerosis has been shown to develop preferentially at sites of coronary bifurcation, yet culprit lesions resulting in ST-elevation myocardial infarction do not occur more frequently at these sites. We hypothesized that these findings can be explained by similarities in intracoronary lipid and that lipid and lipid core plaque would be found with similar frequency in coronary bifurcation and nonbifurcation segments. One hundred seventy bifurcations were identified, 156 of which had comparative nonbifurcation segments proximal and/or distal to the bifurcation. We compared lipid deposition at bifurcation and nonbifurcation segments in coronary arteries using near-infrared spectroscopy (NIRS), a novel method for the in vivo detection of coronary lipid. Any NIRS signal for the presence of lipid was found with similar frequency in bifurcation and nonbifurcation segments (79% vs 74%, p = NS). Lipid core burden index, a measure of total lipid quantity indexed to segment length, was similar across bifurcation segments as well as their proximal and distal controls (lipid core burden index 66.3 ± 106, 67.1 ± 116, and 66.6 ± 104, p = NS). Lipid core plaque, identified as a high-intensity focal NIRS signal, was found in 21% of bifurcation segments, and 20% of distal nonbifurcation segments (p = NS). In conclusion, coronary bifurcations do not appear to have higher levels of intracoronary lipid or lipid core plaque than their comparative nonbifurcation regions.

Femoral artery percutaneous revascularization for patients with critical limb ischemia: outcomes compared to patients with claudication over 2.5 years

Patients with critical limb ischemia have higher rates of death and amputation after revascularization compared to patients with intermittent claudication. However, the differences in patency after percutaneous revascularization of the superficial femoral artery are uncertain and impact the long-term risk of amputation and function in critical limb ischemia. We identified 171 limbs from 136 consecutive patients who had angioplasty and/or stenting for superficial femoral artery stenoses or occlusions from July 2003 through June 2007. Patients were followed for primary and secondary patency, death and amputation up to 2.5 years, and 111 claudicants were retrospectively compared to the 25 patients with critical limb ischemia. Successful percutaneous revascularization occurred in 128 of 142 limbs (90%) with claudication versus 25 of 29 limbs (86%) with critical limb ischemia (p = 0.51). Overall secondary patency at 2.5 years was 91% for claudication and 88% for critical limb ischemia. In Cox proportional hazards models, percutaneous revascularization for critical limb ischemia had similar long-term primary patency (adjusted hazard ratio = 1.1, 95% CI = 0.4, 2.6; p = 0.89) and secondary patency (adjusted hazard ratio = 1.1, 95% CI = 0.2, 6.0; p = 0.95) to revascularization for claudication. Patients with critical limb ischemia had higher mortality and death rates compared to claudicants, with prior statin use associated with less death (p = 0.034) and amputation (p = 0.010), and prior clopidogrel use associated with less amputation (p = 0.034). In conclusion, percutaneous superficial femoral artery revascularization is associated with similar long-term durability in both groups. Intensive treatment of atherosclerosis risk factors and surveillance for restenosis likely contribute to improving the long-term outcomes of both manifestations of peripheral artery disease.